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Guidelines for the Evaluation and Treatment of Dissociative Symptoms in Children and Adolescents
International Society for the Study of Dissociation

The ISSD Task Force on Children and Adolescents is pleased to present the Guidelines for the Assessment and Treatment of Dissociative Symptoms in Children and Adolescents. In utilizing these Guidelines, you might keep the following principle in mind. According to the Criteria for Evaluating Treatment Guidelines of the American Psychological Association (2000), “Guidelines should avoid encouraging an overly mechanistic approach that could undermine the treatment relationship” (p. 2). We hope these Guidelines prove to be useful rather than prescriptive, and improve the care of children and adolescents with dissociative symptoms and disorders. Joyanna Silberg, PhD, Task Force Chairperson These Guidelines are dedicated to the memory of Elaine Davidson Nemzer, 1952-2000.

These Guidelines were developed by the ISSD Task Force on Child and Adolescents and finalized in February 2003. Chairperson: Joyanna Silberg, PhD. Members: Frances Waters, Elaine Nemzer, Jeanie McIntee, Sandra Wieland, Els Grimminck, Linda Nordquist, Elizabeth Emsond. The committee thanks Peter Barach, James Chu, John Curtis, Beverly James, John O’Neil, Gary Peterson and Margo Rivera for critical comments and suggestions. Copyright 2003, by the International Society for the Study of Dissociation, 60 Revere Drive, Suite 500, Northbrook, IL 60062. These Guidelines may be reproduced without the written permission of the International Society for the Study of Dissociation (ISSD) as long as this copyright notice is included and the address of the ISSD is included with the copy. Violations are subject to prosecution under federal copyright laws. Journal of Trauma & Dissociation, Vol. 5(3) 2004 Digital Object Identifier: 10.1300/J229v05n03_09




I. RELATIONSHIP TO ISSD ADULT GUIDELINES The International Society for the Study of Dissociation (ISSD) Standards of Practice Committee issued Guidelines for Treating Dissociative Identity Disorder (Multiple Personality Disorder) in Adults in 1994 and updated them in 1997 (ISSD, 1997). As these made no reference to children and adolescents, the ISSD Executive Council requested the Child and Adolescent Task Force to draft guidelines summarizing current clinical knowledge in the field applying directly to children and adolescents. II. SCOPE OF DIAGNOSES ADDRESSED Although the ISSD Adult Guidelines are specifically directed to the treatment of Dissociative Identity Disorder (DID), dissociation in children may be seen as a malleable developmental phenomenon that may accompany a wide variety of childhood presentations. Symptoms of dissociation are seen in populations of children and adolescents with other disorders such as Post-Traumatic Stress Disorder (PTSD; Putnam, Hornstein, & Peterson, 1996), ObsessiveCompulsive Disorder (OCD; Stien & Waters, 1999) and reactive attachment disorder, as well as in general populations of traumatized and hospitalized adolescents (Sanders & Giolas, 1991; Atlas, Weissman, & Liebowitz, 1997) and delinquent adolescents (Carrion & Steiner, 2000). These treatment principles, therefore, are intended for children and adolescents with diagnosed dissociative disorders, as well as for those with a wide variety of presentations accompanied by dissociative features. In other words, the Guidelines identify general principles applicable to dissociative processes regardless of the child’s1 presenting diagnosis. Diagnosis itself seldom communicates much about the nature of the child and his or her world. These Guidelines are not intended to be a basis for differential diagnosis. While a dissociative diagnosis specifically geared to children has been proposed (Peterson, 1991), this has not been included in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR; American Psychiatric Association, 2000). Although even very young children appearing to meet the criteria for DID have been described (Putnam, 1997; Riley & Mead, 1988), the prevalence of DID in childhood is currently unknown. The diagnosis of Dissociative Disorder Not Otherwise Specified (DDNOS) is the most common in populations of dissociative children and adolescents (Putnam et al., 1996), even though no diagnostic criteria have been set for this diagnosis. While individual case studies of children with
1 The word child is generally used in these guidelines to mean both children and adolescents through high school age.

International Society for the Study of Dissociation


puzzling and atypical dissociative presentations described variously as Depersonalization Disorder (Allers, White, & Mullis, 1997), Dissociative Amnesia or Dissociative Fugue (Coons, 1996; Keller & Shaywitz, 1986), and DID (Jacobsen, 1995) continue to be published in peer-reviewed journals, there is still no real consensus about the typical case and thus no consensus about diagnostic criteria. For this reason, in these Guidelines the perspective on assessment and treatment is symptom-based.

III. INTRODUCTION These Guidelines are derived from the published literature, material from conferences, and the clinical experience of members of the ISSD Child and Adolescent Task Force. As this field is in an early developmental stage, these Guidelines are to be viewed as preliminary. As the field develops, they will be modified to incorporate new research into diagnosis and treatment. In fact, the literature reviewed here, spanning over 16 years of reporting on dissociative phenomena in children, already shows shifts in emphasis and recommendations over time (Silberg, 2000). Despite the changing and provisional nature of our knowledge in this area, it is still important to have some guidelines in approaching dissociative symptomatology for the following reasons: 1. Treatment strategies aimed at increasing integration and reducing dissociation can be highly effective in treating some of the most seriously impaired child victims of maltreatment who are engaged in disruptive and self-destructive behavior. 2. Information on the treatment of dissociation was not available when most clinicians did their training, and it is important to organize clinical information to help familiarize clinicians with current treatment approaches. 3. Without careful consideration of developmental issues, the simplistic application of treatment approaches for adult dissociation to children may be potentially dangerous to children. For these reasons, these Guidelines are presented for the benefit of the ISSD membership and the clinical community at large. It is our hope that research will continue to amend and refine these Guidelines, and that their presentation will stimulate discussion, debate and further analysis that will enrich the field as a whole. These guidelines must be used in conjunction with all ethical

It is important to understand the subtle countertransferential issues that affect therapists who work with traumatized clients (Dalenberg. Heineman. laws or professional regulations that govern the individual’s discipline or place of practice. A good safeguard for “doing no harm” is a solid grounding in child development. As some of these children have suffered some of the most severe forms of maltreatment. 1990. Pearce & Pezzot-Pearce. Myers et al. The most successful treatment approach to an individual case is often the most eclectic. Camaido. 1996. As the literature on the treatment of dissociation in children has come from a variety of treatment orientations. Wieland. information about child and adolescent dissociation is still evolving.122 JOURNAL OF TRAUMA & DISSOCIATION codes. Therapists are advised to be open-minded to a variety of approaches and take the best from each in dealing with the challenges of any individual child or adolescent. develop collegial relationships such as study groups or peer supervision. 1994. Terr. Tinker & Wilson. it is recommended that clinicians treating children with dissociative disorders participate in continuing education conferences. Donovan & McIntyre. 1991. 1998. This is well demonstrated by Cagiada.. 1998). Deblinger & Heflin. with the therapist showing flexibility and creativity in the utilization of a wide variety of available techniques. 1989. IV. QUALIFICATIONS OF CHILD AND ADOLESCENT PRACTITIONERS At this point in the development of this field. Clinicians who treat dissociative children should have training in child therapy and child development through accredited programs in their respective disciplines and be familiar with a variety of treatment approaches for traumatized children (Cohen & Mannarino. 1999. the treatment of dissociative processes in children does not require allegiance to any one particular treatment model. 1997. & Pennan (1997) who successfully treated a boy in a dissociative coma following war trauma using a variety of modalities including hypnotherapy. 1996. Gil. 2000). James. and art therapy. 1997. 1998b. 1996. Prior. collegial support for the therapist is particularly important to avoid secondary PTSD and burnout. health codes. 1996. computer-assisted communication. and stay current with the scientific literature. Friedrich. Readers of these Guidelines are encouraged to adapt these ideas into the frameworks with which they are most comfortable. . In addition. 2002.

Noll. Reiffman. 2001. as well as war trauma (Cagiada et al. Fluctuating moods and behavior. but newer theoretical models stress impaired parent-child attachment patterns (Barach. 1999). Cicchetti. 316). 1997) and trauma-based disruptions in the development of self-regulation of state transitions (Putnam. Newer theorizing ties maladaptive attachment patterns directly to dysfunctional brain development that may inhibit integrative connections in the developing child’s brain (Schore. 1996.” 2. Sroufe.. & Putnam. 2001). including rage episodes and regressions. 2003). Liotti. integration is broadly defined as “how the mind creates a coherent self-assembly of information and energy flow across time and context” (p. Weinfield. 1997) and natural disasters (Laor et al. Sanders & . sense of identity. dissociation may be seen as a developmental disruption in the integration of adaptive memory. Hornstein & Putnam. Dissociative symptoms in children have also been associated with parenting styles described as neglectful (Brunner. 1990. Ogawa et al. 1997.. 5. & Egeland. Parzer. Macfie. may reflect difficulties in self-regulation. THEORETICAL BASIS There is no consensus yet on the exact etiological pathway for the development of dissociative symptomatology. 3. & Toth. According to Siegel (1999). & Resch. 1997. 2000. Siegel. Stien & Kendall. Autobiographical forgetfulness and fluctuations in access to knowledge may reflect incoherence in developmental memory processes. Depersonalization and derealization may reflect a subjective sense of dissociation from normal body sensation and perception or from a sense of self. Dissociative symptoms have been found to correlate with traumatic histories of significant sexual abuse and/or physical abuse (Coons. and the self-regulation of emotion. 2001. Schuld.. Trickett. 1991. Dell & Eisenhower. That is. Children and adolescents may present with a variety of dissociative symptoms that reflect a lack of coherence in the self-assembly of mental functioning: 1. such as trance states or “black outs. 1992. a developmental understanding of dissociation makes the most sense. Siegel sees the development of an integrated self as an ongoing process by which the mind continues to make increasingly organized connections that allow adaptive action. Carlson. Inconsistent consciousness may be reflected in symptoms of fluctuating attention. 1999. From the vantage point of treating children and adolescents. In other words. 2002). The child’s belief in alternate selves or imaginary friends that control the child’s behavior may reflect disorganization in the development of a cohesive self. Ogawa.International Society for the Study of Dissociation 123 V. 4.

& Livesley. & Freyberger. a child’s self-disclosure about fragmented identity or discontinuous experience may allow a sensitive therapist to help the child acknowledge previously disowned affect and experiences. 1999). Lynn. 2. medical procedures. therefore.g. ASSESSMENT In assessing the severity of dissociation. Paris. and eventually achieve developmentally normal integration. events that have not necessarily been defined as major trauma (e. such as fantasy-proneness (Rhue. In the best-case scenario. 1995) or other inherited personality traits (Jang. While not all trauma necessarily results in dissociation. 1998). minimize self-destructive and disruptive behavior. it must be noted that each child’s reaction to life events is a constructive process that is idiosyncratic. VI. consciousness or memory impede the achievement of normal developmental tasks. and what might overwhelm one child may not overwhelm another. Spitzer. rejecting and inconsistent (Mann & Sanders. & Sandberg. increase personal responsibility. However. 1994). Those assessing children and adolescents should keep this therapeutic goal in mind. 336).124 JOURNAL OF TRAUMA & DISSOCIATION Giolas. There may be individual differences in children’s susceptibility to dissociative symptoms that may be related to other traits.. 3. repetitive losses of attachment figures. Considerable controversy remains as to the contribution of genetic factors in the development of dissociative symptoms (Grabe. Zweig-Frank. chronic living instability. 1991). peer rejection. 4. General Framework Diagnosis may include the following components (* these are essential): 1. observation of domestic violence. can aim to provide those new interpersonal relationships that foster the integration and coherence of self. and improve adaptation. Therapeutic intervention. it is important to determine how disruptions of identity. According to Siegel (1999). A. emotional abuse) have nevertheless been found in the backgrounds of children displaying dissociative symptoms. “interpersonal processes can facilitate integration by altering the restrictive ways in which the mind may have come to organize itself” (p. Screening tests Clinical interviews * Structured clinical interviews Psychological testing .

the family. somatic concerns. Lewis. and identity alteration and confusion (see Symptom Assessment below). nightmares. numbing. Farrington. In interviews of the child. 1993). Dell. sexual concerns. sources of . b. is the basic starting point for assessment. Vandereycken. dysfunctional family patterns. auditory and visual hallucinations. The family environment: physical and emotional safety. Vanderlinden. the Children’s Perceptual Alteration Scale (CPAS. Smerden. 6. & Trickett. Screening tests These are useful. Armstrong. Smith & Carlson. flashbacks. family secrets that may impact on the child. Waller. though neither essential nor diagnostic. 2. One self-report questionnaire that may prove to be diagnostic is the adolescent version of the Multi-Dimensional Inventory of Dissociation (MID. and may alert the clinician to more depth interviewing of child and caregivers regarding dissociative symptoms and experiences: a.International Society for the Study of Dissociation 125 5. self-injury. 2002). & Verkes. 1994). Dell. which has excellent validity and reliability (Putnam & Peterson. 1. Putnam. & Smith. Ruths. and the Dissociative Questionnaire (DisQ. history of psychiatric illness of all family members. depersonalization and derealization. Self-report questionnaires for the child include the Adolescent Dissociative Experiences Scale (A-DES. 2001. as have cautions in interviewing (Silberg. 1996). Clinical interviews A complete history. b. Imaginary friends and other transitional objects. 1996). Helmers. Silberg. 7. 1993). Fairly structured interviews have been described (Hornstein. & Jenkins. intrusive thoughts and feelings. Carlson. 8. from reliable informants as well as from the child. 1998c). Libero. & Faupel. perplexing forgetfulness. 2002. 1998. pay attention to the following: a. and of other third parties. Comorbid conditions * Medical evaluation * Pharmacological and hypnotic interventions Ongoing assessment during treatment. 1992). 1997. Vertommen. Van Dyck. Caregivers may screen for dissociative behaviors with the Child Dissociative Checklist (Putnam. anxiety. Evers-Szostak & Sanders.

3.. multi-generational history of dissociation (Braun. Structured clinical interviews No diagnostic interview schedules have been validated for children and adolescents. the family’s investment or interest in. 2000.126 JOURNAL OF TRAUMA & DISSOCIATION support outside the immediate family. Medical evaluation The evaluator must rule out general medical disorders that may mimic dissociative symptoms. traumatic imagery. Perpetuating factors are important for appropriate treatment planning. Balancing predisposing. c. and specific developmental disorders (Hornstein. 4. even if the dissociative patterns were established at an earlier age. Attention Deficit Hyperactivity Disorder (ADHD). substance abuse disorders. and evidence of a passive problem solving style (Silberg. The latter includes current life circumstances that maintain the disruptive symptoms. eating disorders. 5. Current practice guidelines (American Academy of Child and Adolescent Psychiatry. 1985. Steinberg & Steinberg. Comorbidity assessment Comorbidity is common with dissociative disorders. Behavioral signs and response features typical of dissociative patients include forgetting. The child’s functioning in other settings. Coons.g. Formal psychological testing This is not diagnostic. 1985. Steinberg. 1998. 6. school. c. 1998). but may be corroborative. affective disorders. Peterson. 1998b). These include seizure disorders. Yeager & Lewis. e. 1994) has been used for adolescents who can maintain adequate attention and have an average or higher level of cognitive functioning (Carrion & Steiner. 1998) may be helpful in screening for: Obsessive-Compulsive Disorder (OCD). precipitating and perpetuating factors. 1995). dissociation. as families may try to focus exclusively on the child’s past history and resist looking at their own current dysfunction. 1996). movies or family conversations. other neurological . reactive attachment disorder (RAD). or understanding of. d. However. PTSD. Areas of specific relevance to dissociation: the child’s familiarity with material about dissociation from books. with peers. practices or beliefs which are unusual for the family’s culture and ethnicity. the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D.

c. where the child’s receptivity to intervention can be continually assessed. but not both. parents. b. allergy. hypnosis is recommended only as an urgent assessment/intervention strategy for reaching severely unresponsive children where other methods have been ineffective. some children will present for evaluation with both dissociative symptoms and a documented legal and social service history of trauma. For these reasons. Trauma Assessment 1. . exposure to toxins. there are legal complications in the United States of America which may also apply in other jurisdictions: the legal guardian must give explicit permission. The treatment team ought to plan frequent assessments of dissociative symptoms in order to gauge progress. or legal or illegal drug effects (Graham. b. 1996). the family. 1998. B. But others will present with just the symptoms or the history. and sensitivity to this level of analysis may encourage integrative problem solving for the team. Assessment should be guided by pragmatic concerns about how to best interrupt disruptive behavior. including legal risks regarding the possible inadmissibility of testimony in future court proceedings. 1993. 7. Lewis. and where multiple inputs from teachers. Kluft. risks must be explained. still others will present with neither symptoms nor history. and other observers of the child can be obtained in an ongoing way. Ongoing assessment during treatment a. 1985. Williams & Velazquez. However. Sodium amobarbital or other pharmacological interventions are not recommended in the assessment of children and adolescents. 1996). Thus. Sometimes dissension in a team replicates contradictory pulls within the family or child. There is mild support for the use of hypnosis as a diagnostic tool for assessing children and adolescents for DID or DDNOS (Benjamin & Benjamin. The best assessment is that which takes place in the context of ongoing therapeutic work. and the child. Pharmacological and hypnotic diagnostic probes a. Dissociation and trauma There is a strong correlation between traumatic events and dissociative symptoms. Diagnosis may become a source of conflict and dissension among members of the treatment team.International Society for the Study of Dissociation 127 conditions. 8.

1997). though such a history ought to prompt a closer examination for dissociation. which may affect the child or family’s report of trauma. Fivush & Schwarzmueller. .. 1995. Peterson & Biggs. When there are dissociative symptoms. Beware of inaccuracy. no disclosures by the child. Later disclosure by the child. e. The child may manifest instead the conditions commonly comorbid with dissociation (see above). painful peer rejections. 1993. Cautions in assessment a. loss of a parent through separation. sexual abuse. including that they may be true (Everson. the clinician ought to conduct a thorough assessment of traumatic events in the child’s history. Continue to assess and reassess as new information becomes available. deceit. and involvement in organized criminal activities such as child pornography or sex rings (Bidrose & Goodman. 2000). This would include: a. illnesses of the child or other family members. c. emotional abuse. other losses or experiences with death. Physical abuse. such as sexual abuse or other specific trauma. or the lack of records. distortion. the family or other witnesses to abusive acts may occur over the course of an extended assessment period. but no documented trauma history. The trauma history may be masked by the child’s amnesia. Neglect. Keeping the aforementioned in mind. the family’s denial. or other witnesses to abusive acts. Loss such as death of a parent. manipulation. the child will not necessarily have dissociative symptoms. without dissociative symptoms per se. witnessing violence. When there is a clearly documented trauma history. b. 1998. the presence of dissociative symptoms or disorders are not in themselves sufficient evidence of prior trauma. 2. Avoid suggestive questioning in evaluating children’s responses in interview (Coulborn-Faller & Everson. the family. Keep in mind multiple hypotheses about the reasons for reports of seemingly bizarre and improbable traumatic events.128 JOURNAL OF TRAUMA & DISSOCIATION a. c.g. or confabulation. Goodman & Bottoms. 3. 1997). inadequate attachment. b. b.

Follow professional guidelines (American Professional Society on the Abuse of Children. sexual abuse experiences may not be as accessible to recall. 1996). but display knowledge of events through sensori-motor modalities or somatic symptoms instead (Burgess. 1998). While the frequency of traumatic amnesia in children and adolescents is unknown. when the source of abuse is also the source of nurturing (Freyd. C. 5. 1996). behavioral re-enactments. Evaluators ought to be sensitive to how children’s play. d. 1997. art. Because children’s memory is enhanced from practice and rehearsal and is superior for events that are familiar (Ornstein. clinical experience suggests that children and adolescents may have sudden recall of previously unavailable traumatic memories during or outside of therapy sessions. c. & Baker. Symptom Assessment In assessing the severity of dissociative symptoms. Duggal & Sroufe.International Society for the Study of Dissociation 129 c. American Psychological Association. Stien & Waters. 1995). 1995. Some autobiographical amnesia is a normal developmental phenomenon (Siegel. Murachver. In taking a trauma history–just as with the assessment of dissociative symptoms–attention to past stressors ought to be balanced by attention to current stressors (perpetuating factors). 1997. 1991). Children may lack verbal memories for traumatic events. Terr. & Reese. and somatic concerns may be reflections of or communicate information about traumatic events. violent threats from a perpetrator may produce powerful incentives to dismiss certain traumatic events from conscious awareness so that a child can more effectively cope with day-to-day expectations. as these may promote continued dissociative adaptation. Pipe. This process has been documented in cases where the traumatic events were corroborated (Corwin & Olafson. e. 1997. Memory for traumatic events for children in incestuous families may also be affected by the intense contradictory pulls for attachment and for safety. Fivush. 1998). 4. take into consideration how severely the symptom disrupts normal developmental experiences like . In addition. b. especially when shrouded in secrecy. 1999. Hartman. Trauma and amnesia a.

. More common is amnesia for past traumatic events. Dissociative pathology is suggested when the involvement in fantasy interferes with normal activity. Lewis. and how far the child’s behaviors and experiences deviate from what is characteristic of normal developmental phenomena. Trujillo. out of guilt or shame. parents may report the child has no memory for an event. to states described as coma (Cagiada et al. what consequences these disruptions have for the child. when they experience the imaginary playmates as real. & Gidlow. Provide abundant contextual clues. Asking children about whether they forget good things (good grades. or attending school.. Imaginary playmates Take special care to differentiate normal imaginary playmates and fantasy material from pathological dissociative symptoms. and what the child experiences during these states. what seems to interrupt them. to excessive sleeping or fainting. 3. when the children feel their behavior is outside of their control. to longer periods of non-responsiveness. Trance states Trance states or “black outs” may span the range from momentary absences of attention (normal in children and adolescents).. 1998) may help discriminate between amnesia and unwillingness to report. Determine what elicits these absences in attention. Help the child express feelings associated with the forgotten behavior. as well as misbehavior or angry episodes (Hornstein. Other useful techniques for assessing memory problems are the following: • • • • • Gently inquire with the parent out of the room. children may use the expression “I forget” as a distraction. 1. Decrease the child’s sense of shame. Role-play the forgotten behavior. 1996). and diagnostic of a more severe dissociative process. Amnesia and transient forgetting True amnesia about one’s own recent behavior is quite rare. More common still is transient forgetting which quickly disappears after the child is working with an empathic therapist. and when the they perceive imaginary figures in conflict with each other (Silberg. or because of lack of rapport with the interviewer. 1997).g. 1998c. 2. birthday parties). how long they last. e. Yeager.130 JOURNAL OF TRAUMA & DISSOCIATION playing with friends.

derealization. Distinguish this from depersonalization and derealization complicated by substance abuse. or suddenly talking about oneself in the third person or with a new name are shifts that suggest difficulty in the integration of affect. encouraging caregiving behavior. Instead of encouraging the child or adolescent to switch to alternate identities. rageful behavior. 2000). or identity shifts. the stimulus may be a feeling associated with a traumatic event or associated thought which children find too frightening or embarrassing to acknowledge. and identity and are consistent with DID. even if these are not at first obvious. ability or perceived identity. mood. 6. some therapists argue that refractory cases of severe dissociation in adolescents may require more directive assessment and interventions (Kluft. and communicative meanings. Depersonalization. goals. and puzzling. Identity alteration and changes of state Some children may feel the presence of internal others. Making these connections will give you a better idea of the child’s receptivity to therapy and the severity of the dissociation. intentions. personalities. Even during the assessment. consciousness. use child-familiar language. Then evaluate the child’s memory for the state change. expression of rage). Frequently. . etc. Sudden regression. ego states. self-states. 1996). and help the child make connections between feelings and behaviors and explore alternative coping strategies. all these terms are synonymous). apparent loss of consciousness. That being said. substance abuse Some feelings of transient depersonalization are common in adolescents. Don’t be too suggestive in questioning as this may encourage the child to feign behavior to please the evaluator.e.International Society for the Study of Dissociation 131 4. try to connect these initially puzzling changes with the child’s own perceptions. Children with dissociative symptoms often have very colorful ways of describing these phenomena that make it clear that they experience these changes as dramatic. which may contribute to it (Carrion & Steiner. 5. encourage the child to make the internal connections that promote awareness of other states. or “self-states” (Peterson. Children normally go through changes in affect and behavior during the course of an interview. Assess the family’s and others’ reactions to these shifts for a context for understanding some of the ongoing shaping influences that may promote dissociation. uncontrollable. feelings. If a child is observed to shift behavior or affect spontaneously during the evaluation without direction from you. try to determine which stimuli elicited the shifts in state and to understand the functions of the state switches for the child (i. alters. Be careful not to over-pathologize normal state shifts.. 2000). Inquire about the subjective sense of discontinuity and about any stimuli that preceded a change in state. affects. (for the purpose of these Guidelines. avoidance.

such as nightmares. dream-like state. such as numbing and avoidance. VII.g. scratching. An optimistic attitude facilitates recov- . which includes symptoms of loss of physical sensations. 8. TREATMENT A. 1997). hitting. This behavior may be secret. and may be performed in a dissociative trance state. Inquire as to relief experienced by such self-harm. Post-traumatic symptoms These include positive symptoms. Gently inquire about all stages of self-harm (cutting. 2000) may also assist with this evaluation (see also Nader. Somatic symptoms Inquire about somatic symptoms (e. Van Dyck. planning. robotic state. as the infliction of external pain commonly reduces internal pain.e. as some or all stages may be done in a dissociated state (depersonalized.. or used to facilitate or interrupt such a state. i. disturbing hypnagogic hallucinations. unusual pain tolerance or pain sensitivity. and recuperation. as well as negative symptoms. & Vanderlinden. or head banging. intrusive traumatic thoughts and memories.). 2002). which may include cutting. Most child and adolescent cases of severe dissociation are not as difficult and lengthy as adult cases. re-experiencing or flashbacks. and traumatic re-enactments. and other sensori-perceptual anomalies (Nijenhuis.132 JOURNAL OF TRAUMA & DISSOCIATION 7. night terrors. Johnson. sexually reactive. Length and Course of Treatment 1. burning. 2001. burning... may serve an affect-regulating function. Standardized screening instruments such as the Trauma Symptom Checklist for Children (TSCC. The Trauma Symptom Checklist for Young Children (Briere et al. Spinhoven. trance state. stomach aches.). preparing.. Distinguish between normal sexual behaviors. other undiagnosed pain) as well as somatoform dissociation. doing. Van der Hart. Briere. headache. Sexually reactive or sexual offending behaviors may occur in traumatized children and may co-occur with dissociative symptomatology. 9.. etc. 2001) or the Children’s PTSD Inventory (Saigh et al. numbed. Self-injurious behavior is common among dissociative teens. and sexually molesting behaviors in children and adolescents and evaluate the role dissociation plays in the maintenance of these (Friedrich et al. 1996). 10. 1996). etc.

It is appropriate to maintain an open-minded and hopeful stance about the possibility of rapid treatment. 1997). and consistency in approaching the child within all settings may help to promote integration and defeat dissociative barriers. Continuity in the therapist’s relating to the child across all changes of state is a key ingredient in the therapy. if needed (Kluft. 2. as well as on understanding the internal influences that affect the child’s ability to contain destructive or disruptive behaviors. including disowned experiences and affects that the child may perceive as being contained in voices. even for the most severe presentation. 3.International Society for the Study of Dissociation 133 ery. B. No child can be fully treated in isolation. but must rely on the severity of the patient and family circumstances and family constraints. Peterson. Silberg & Waters. and any significant others involved in the case. 2001c. As with all treatment of children. Adolescent therapy in cases of unstable families may have more limited goals of crisis intervention and promotion of stability with intermittent services (Wieland. Despite the refractory nature of many adolescent cases (Dell & Eisenhower. 2001a. 3. However. pediatrician. Therapists must forge an empathic connection with the whole child. 1998). Silberg & Waters. Therapists must acquaint themselves with all members of the team and develop a format for regular communication. treatment efforts should work to stabilize placements. Length or frequency of treatment cannot be prescribed. Role of the Therapist 1. therapist. Silberg. so that the child feels fully accepted at all levels of experience. In some cases. Kluft & Schultz. This empathic connection is key for the child to begin to accept his/her disowned experience and affect and to take responsibility for moving on. 1985. 1990. imaginary friends or self-states. the therapist must balance confidentiality offered to the child with the legal rights of custodial parents for ac- . 1984. 4. 1993). 1998). 1990. Treatment of children and adolescents with the severity often presented in these cases is often a team effort involving parent. 2001b. there are many cases of successful outcome as well (Dell & Eisenhower. school. With younger children in unstable homes. 2. The therapist must assess at the outset the availability of resources and plan for the eventuality of more restrictive services. 1996. as this has occurred in many cases (Kluft. multi-disciplinary coordination can often prevent the need for more restrictive services. 1996). treatment can be intermittent as the child’s needs change. Communication within the team should focus foremost on safety and support for the child and development of consistent expectations for the child.

Clinicians must follow reporting guidelines within their own regional jurisdictions. A stance of gentle. 5. or music. Overly special or zealous interventions (e.. evaluate safety in the environment. 4. Families may defensively concentrate on the past and avoid discussion of the current stressors that maintain dissociative adaptations. An important goal of therapy is for the child to learn increasingly adaptive and flexible ways to manage affect and to integrate past. or guardian ad litem regarding the therapist’s findings.g. 3. The therapist should help the family find creative solutions to current problems. The therapist should recognize his/her role as a potentially powerful reinforcer and shaper of the child’s or adolescent’s behavior. isolating children from peers or school for long periods of time. court testimony. The child should be encouraged to participate in normalizing activities such as sports. and seek other consultations regarding how to modify the treatment approach so that the child is progressing along a developmental trajectory that is as normalizing as possible. empathic. current. imaginary friends or self-states that they perceive as affecting their behavior. ..g. and may support a family’s or system’s entrenched beliefs about a child’s incapacities. visitations. Achievement of physical safety is a primary goal that supersedes any other therapeutic work. evaluate possible stressors (e. If the child appears to be regressing in therapy. 2. art. non-judgmental listening and open inquiry may encourage children to describe in their own language the contrasting influences. the therapist should review the course of treatment. and new experiences so that development is not compromised. too much focus on traumatic events). physical restraint systems) tend to reinforce dissociation rather than curb it. C. court-appointed attorney. case worker. Reports to local child protection services are required whenever issues of child maltreatment are suspected. In cases where the therapist concludes that current legally-dictated arrangements are not in the child’s best interest.134 JOURNAL OF TRAUMA & DISSOCIATION cess to records and to information that may have life-threatening implications and must disclose policies regarding this to both child and parent at the outset of therapy. it is the therapist’s obligation to provide recommendations to the child’s current caregiver. Special Cautions in the Treatment of Dissociative Symptomatology The following are common pitfalls in working with dissociative children and families: 1. advocate.

Therapeutic Goals 1. The therapist must help the child and the family understand that any self-states or alternate identities are really part of the child and that the whole child is responsible for his/her behavior. Help the child achieve a sense of cohesiveness about his affects. D. responsible person must be emphasized. 6. treatment gently highlights the motivations. while assisting the child to accept responsibility for the disowned behavior or affect. over time. Therapists should stay alert to the need for referral of the parents for treatment when the parents’ own mental health issues interfere with the child’s treatment. The therapist can help the child gain increasing control over the behavior. in part. the therapeutic goal is to increase in the child a sense of awareness of his/her feelings and responsibility for associated behavior. 7. Enhance motivation for growth and future success . When the child perceives that the behavior is controlled by an imaginary friend or other dissociated aspect of the self. and parents must continue to impose these limits despite the child’s sense of frustration. 2. and the adults must be cautious not to unwittingly increase dissociation through undue emphasis on separateness. cognitions. This frustration is. All treatment should include intervention with the family currently providing care to the child or adolescent. The family needs to be encouraged not to ask for the “good child” or the “good behavior” but to interact with the child as a whole. and associated behavior Although the child may perceive his/her emotions and behavior as outside of his/her own control. this promotes a cohesive and integrated sense of self. The family needs to be helped to understand the child’s fears and underlying anger without accepting these as excuses for irresponsible behavior. unified. This intervention can occur as part of the regular therapy or from a separate family therapist with close coordination. what stimulates the internal awareness (or co-consciousness) that leads to change. memories and feelings that the child has had trouble integrating into central awareness and. The therapist gently but firmly should help the child to accept responsibility when limits are imposed for behavior that feels outside of his/her control.International Society for the Study of Dissociation 135 while exploring feelings from past events that continue to contribute to current difficulties. The child as one.

Help the child believe in his/her own skills and potential. Educate about how dissociation prohibits growth and change. so that over time there is no longer a need for dissociative escape or a fragmented sense of identity. and problem-solve towards integrative solutions. and brought to conscious awareness by the therapist’s comments. This helps break down dissociative barriers. loyalties. contrasting role expectations or dissociated feelings are enacted in play. can encourage a natural integration and development of cohesive identity in younger children (Albini & Pease. 1996. Shirar. The child may perceive these as conflicts between internal voices. grief. fear. Kluft. 1989. Enhance motivation for success and future accomplishment. disappointment. 1996. Waters & Silberg 1998b). 1985. Gestalt techniques involving dramatizing and thus giving voice to a variety of opposing feelings (Shirar. or by imagery and hypnotic techniques (Gil. Waters & Silberg. shame. c. or contrasting expectations a. Education about sexuality (Wieland. 3. 1998a. Laporta. and remind the patient of these feelings when they are not immediately accessible. self-doubt. b. and how they can affect one’s developmental integration. This encourages the child to abandon dissociative strategies over time. With teenagers. identifications. b. examine both sides of the conflict. or conflicting identities. Promote self-acceptance of behavior and self-knowledge about feelings viewed as unacceptable a.136 JOURNAL OF TRAUMA & DISSOCIATION a. physical pain or sexuality. Enhancing knowledge about these helps promote integration. This promotes integration and helps defeat the resistance to change. imaginary friends. Play therapy in which these various conflicts. 1998) and affect may assist with this process. Dissociation may protect the child from awareness or experience of his/her own feelings of rage. Education on early implicit memories. b. 1998b) may stimulate this process of self-awareness and promote acceptance of dissociated feelings. This may be facilitated by specific play activities. 1993. wishes. McMahon & Fagan. The therapist helps the child find ways to express these conflicts directly. 1991. Model the acceptance of all contrasting feelings. Help the child resolve conflicting feelings. can also help both children and parents understand the child’s experience of dissociation. some therapists rec- . 4. 1992).

Desensitize traumatic memories. Traumatic re-experiencing may take the form of flashbacks. 1996. 1989). . The child’s access to these memories may be variable as treatment progresses. For example. so understanding the complete context in which these flashbacks occur is essential before recommending interventions. 1998). 1991. 1991. Be careful to titrate discussions about traumatic content and not overwhelm the child (James. Talk to the child about overwhelming experiences and their associated affects and perceptions. techniques that help improve the child’s sense of efficacy and mastery are encouraged (Friedrich. Gil. 1991. 1996) may be helpful. Play therapy with trauma patients tends to involve more active intervention for re-working of traumatic themes than other kinds of play therapy. James. and correct learned attitudes towards life resulting from traumatic events a. b. Tinker & Wilson. Ego-strengthening and calming techniques are advisable prior to using EMDR to avoid destabilization. Williams & Velazquez. These exercises promote self-cohesion without reinforcing the separateness of identities. such memories may become more accessible. However. Eye Movement Desensitization and Reprocessing (EMDR) can assist children in working through experiences for which they have very little or no explicit memory or experiences that they find too difficult to talk about in detail (Greenwald. Therapists should take note of situations where these conflicts cannot be resolved without a concomitant change in the environment. 1998) or formal hypnosis to guide the child towards mastery experiences (Friedrich. 5. Imagery techniques (Wieland. This helps to desensitize the child’s conditioned fear responses to any frightening memories. The child alone cannot resolve this unless the environmental pressure is relieved. as the child moves towards a more cohesive sense of self. children may be caught in custody battles–with widely divergent expectations between parents–that may lead to a fragmented sense of identity.International Society for the Study of Dissociation 137 ommend having the client write letters to him/herself or dramatize internal dialogues aloud to facilitate resolution of competing wishes or feelings. Some traumatized children engage in flashbacks during parental fights or when asked to do chores. in which the child or adolescent experiences past events as if they were really happening. 1993. 1999). When dealing with traumatic content. Families can set designated times to discuss unpleasant memories so that these do not interfere with daily functioning (Waters. 1994).

Encourage children to communicate feelings of anger. b. Promote healthy attachments and relationships through direct expression of feelings a. interrupting dysfunctional impulsive habits. 2002). 1996. Gently pointing out these contradictions within the context of an accepting therapeutic relationship eventually promotes integration. Promote autonomy and encourage the child to independently regulate and express affects and to self-regulate state changes a. talking to adults. belief in a bad self. and engaging in drawing. James. 1999) with associated beliefs that may make this aspect of treatment particularly challenging. fear. and being unlovable. or contradictory attachment styles (Liotti. Cognitivebehavioral techniques can help children learn to manage self-destructive and impulsive behavior. 1997. 1989). Children can be reinforced for identifying changes in moods or states. Wieland. Therapists can teach children techniques of promoting active attention that may help interrupt sexual misbehavior or other disruptive behavior that occurs during dissociative states (Johnson. and families must assess ways in which they can learn to reinforce positive methods of affect-regulation. Gil. Deblinger & Helfin. 1998. 7. Teaching use of positive imagery and relaxation for self-soothing and stress reduction may be useful. Dissociative children may hold contradictory beliefs. and these beliefs need to be corrected in the therapy (American Academy of Child and Adolescent Psychiatry. Children engaging in repetitive self-harm must learn alternatives such as more direct feeling expression. Therapists can help children identify precursors to state changes so that they become better at self-monitoring (Allers et al. Self-monitoring may be encouraged by use of special code words whereby a parent or teacher can let a child know a shift has occurred.. Self-injury may become a mood-altering addictive behavior that serves to distract from emotional pain or express feelings of despair and anger. 6. improved methods of mood regulation. writing. 1997). or these words or slogans can stimulate focused attention. Traumatized children may develop a variety of learned attitudes that may include helplessness. 1991. or other expressive alternatives. including impulsive sexual behavior. and regressive needs to their caregivers so that these are not enacted in .138 JOURNAL OF TRAUMA & DISSOCIATION c. being destined for bad things. c.

and straightforward parenting advice or training which is part of all good child therapy. Parents can be taught to encourage the child’s direct expression of thoughts and feelings without reinforcing dysfunctional dissociative strategies. Silberg. E. 1998). 2000. 2001). Teach caregivers to tolerate these direct expressions. In educating parents.International Society for the Study of Dissociation 139 dysfunctional ways. 1998b). This would be a time when the therapist. such as family indulgence or overly punitive responses in the face of regressive behavior. This promotes healthy attachment though it may be difficult for families that are uncomfortable with affect and have poor boundaries. family sessions to encourage the family to accept all aspects of the child (Waters & Silberg. d. For children residing in original homes in which maltreatment or unintentional exposure to traumatic events occurred. correcting interactive patterns that promote dissociation (Benjamin & Benjamin. particularly for children and families from chaotic environments. Silberg. helping parents process guilt or denial about traumatic events (Keren & Tyano. in press). parent and child can develop ideas for handling problem situations at home. 1991). Work with the primary caregivers may include education about dissociation (Waters. Family therapy a. change any literal views the family may have about the reality of “alters” as separate from the child. working through of feelings about issues of safety and betrayal to help establish trust (Waters. 1998). b. while explaining how dissociation evolves in a traumatized child. Help families and children view the therapist as a stable attachment figure. specific guidance about parenting strategies which facilitate therapy (Boat. b. Dyad work with the parent figure and the child can be particularly valuable in helping the therapist understand the subtle negative dynamics that may be occurring in the home. Adjunctive Treatments 1. c. The therapist can also help the family identify current reinforcers that maintain the symptomatology. . acknowledgment of the trauma and an apology for the lack of protection is a basic starting point for much of the family therapy work. 1993.

Promoting positive peer interactions may help build in long-term resiliency for children and adolescents. . OCD. and art therapy from a licensed art therapist may be a useful adjunct to individual treatment in some cases (Sobol & Schneider. Most child therapists use some art in their work.140 JOURNAL OF TRAUMA & DISSOCIATION 2. 4. major depression. c. lability. Group therapy Group therapy may be useful. 2000) or for containment of intense affect. 5. Putnam. Medications may be utilized to treat co-morbid conditions such as attention deficit hyperactivity disorder (ADHD). Some clinicians have found that psychotropic medication may be of benefit for children and adolescents with dissociative symptoms and disorders as an adjunct to psychotherapy to ameliorate targeted symptoms such as incapacitating anxiety. Dell & Eisenhower. insomnia. Pharmacotherapy a. the therapist should gain informed consent from caregivers or guardians. & Coons. 1985. and support (Williams & Velazquez. or PTSD. 1997. Silberg. 1998). Blix. The therapists should explore all legal implications. inability to focus attention. 1998. Close communication and teamwork between the prescribing physician and the therapist is essential. b. Hypnotherapy Hypnotherapy for children and adolescents has been described for rapidly accessing ego states and promoting integration (Bowman. adolescents or adults. particularly if it is psycho-educational in orientation (Brand. d. 3. behavioral dyscontrol. Silberg et al. ego strengthening. given that witness credibility for any upcoming court hearings could be affected. 1997). 1985. 1997). education. Kluft. However. limiting the latter if it simply becomes a form of traumatic re-enactment without trauma resolution. Stipic & Taghizadeh. as well as clients. In cases where hypnosis is deemed appropriate. 1998. hypnotherapy is not advised for memory retrieval. and depression (Nemzer.. There are no controlled studies on the use of medications with dissociative children. 1996). 1990. Art therapy Strike a balance between art that encourages mastery and art that is regressive.

Instead. e. avoid hospitalization. such episodes may be worked through with the child or adolescent. f. . The child’s belief that other parts of the self were responsible for the misbehavior should not be viewed as the child willfully escaping responsibility. and follow through with appropriate consequences. If seclusion or therapeutic physical containment is required for destructive behavior. the child should be gently encouraged to take ownership of the feelings associated with the destructive behavior. more frequent sessions during a crisis. it is essential that these procedures be explained to children in advance. Inpatient/residential treatment a. processing of traumatic material. 1991). which may be directed towards the self or others. or respite care. Admit dissociative children and adolescents to inpatient care when they are engaged in dangerous. b. The goal of the inpatient or residential treatment is to stabilize behavior by identifying the internal motivation for the dangerous behavior. However. as this stance may serve to increase oppositional behavior. Once calm. if possible. Admit children or adolescents to residential treatment if they requires ongoing close monitoring and a carefully structured environment for their own protection or protection of others. The hospital or residential center must have the structure to provide protection to children from their destructive impulses. or where the child is at risk and needs a safe environment for a complex assessment (Hornstein & Tyson.International Society for the Study of Dissociation 141 6. and learning appropriate problem-solving. c. If the child presents as having no memory for the experience. Staff members dealing with dissociative children and adolescents should have basic familiarity with dissociative and post-traumatic reactions and know how to help children with the experience of flashbacks and post-traumatic anxiety. through close monitoring. A more intensive treatment milieu may be needed for stabilization. and negotiating and resolving internal and external conflicts until commitment to safety is achieved. while exploring constructive ways to gain control. so that they can best identify traumatic associations or internal and external stimuli that prompted this behavior. the staff can gently explain what the behavior involved. which may not be readily accessible to the child if dissociated from awareness. and from re-traumatization from other residents or patients. d. self-injurious or destructive behavior that cannot be contained in a community environment.

to provide for a smooth transition to discharge. Incorporate expressive arts into the curriculum for expression of feelings (Waterbury. c. Children and adolescents with dissociative symptoms may require special education modifications if their disruptive behavior. b. should set clear and firm limits about expectations. The staff should encourage children and adolescents to monitor themselves to access their greatest potential. The school staff should convey an attitude of understanding and reward effort and approximations of desired goals. or legal advocates. and provide regular opportunities for the child to communicate about sources of stress in the school environment or at home that may impact on performance. and an attitude of gentle accountability is encouraged. or internal states that led to the destructive behavior. d. such as age regression. mood instability and poor attention interfere with academic functioning. or teachers) with whom they have a special relationship and with whom they can communicate frequently (Kobak. many children with dissociative symptoms can succeed in regular classrooms. An approach that deals only with observed behavior and is based solely on behavior modification will. advisors. in most cases. Educational interventions a. Designate one member of the staff to deal with any dramatic shifts. h. Discourage special attention from other students related to extreme shifts in behavior. however. Race. 7. Pre-arranged code words or signals that stimulate attention and focus may be useful (see above). f. It should be assumed that the child or adolescent will bring his/her full potential to the school setting. School staff should help encourage the child or adolescent to stay focused even while mood and attention fluctuate. 1998). It is important to help the child plan for future similar events. e. . This kind of approach will not assist with identifying the feelings. so that the child achieves the self-control necessary to move to a less restrictive environment. The setting should provide close cooperation with the child’s outpatient therapist. With supportive staff. Be attentive to the children’s needs to have stable attachment figures in the school setting (counselors. traumatic stimuli. protective service workers.142 JOURNAL OF TRAUMA & DISSOCIATION g. 2002). be inadequate. Little. & Acosta.

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